All Entries Tagged With: "Maryland"

The Maryland ACDIS Chapter has been meeting for more than five years. Although previously under the auspicious of the Maryland Hospital Association (MHA) (which still graciously houses the group’s monthly meetings), the group became an “official” ACDIS chapter back in 2013.

On Friday, December 5, 12:30- 3 p.m., at the MHA headquarters in Elkridge, the group once again hosts its annual holiday pot luck event. In addition to inviting attendees to bring a tasty tidbit of food to share, the group also collects donations for Toys for Tots Foundation.

In fact, many local chapters have incorporated charitable giving into their meeting agendas. The North Carolina and Virginia ACDIS Chapters often ask the host facility to identify a charity in their area and a donation suggestion. Often hosts choose nearby food pantries, collect canned goods, and deliver the items following the event.

Such charitable efforts go above and beyond expectations as leaders, hosts, and even attendees often come to local meetings on their own time and on their own dime taking personal time off to attend and working after hours to ensure the event’s success.

Kudos to all who not only ensure the sharing of CDI wealth but who share their good fortune with those less fortunate in their vicinity. For information about the upcoming Maryland event email Andrea Norris at anorris@uchs.org.

Cost is $10 for chapter members and $25 for non-members. Registration is limited to 75. Call 843-792-8136 or email lynli@musc.edu. Staying overnight? Contact Guest Services at MUSC for discount hotel reservations (first come, first serve) at 843-876-8456. Identify yourself as a member of the MUSC ACDIS conference.

Wisconsin

The Wisconsin ACDIS Chapter meets Saturday, May 31, 9 a.m. to 3:30 p.m., at the Wheaton Franciscan Wauwatosa Campus in Wauwatosa. The spring meeting’s theme is “Maintaining Relevance to the Practice of CDI,” featuring:

“Thinking like a Clinician: Understanding the physician’s clinical thought processes and medical decision-making in developing an assessment and plan,” by Mitch Hulbert, MD, from Columbia St-Mary’s Hospital in Milwaukee.

Q: We continue to struggle with documentation regarding respiratory failure post surgery. Is there any new information or ideas about how to navigate this topic with the physicians?

A: I think the prevailing attitude in the CDI world is that delayed extubation after surgery is not respiratory failure. American Hospital Association (AHA) Coding Clinic for ICD-9-CM, third quarter, 2010, addresses the coding of mechanical ventilation stating that the threshold after surgery is generally 48 hours, but I do not believe that there is the same guidance regarding respiratory failure after surgery.

The provider can document the diagnosis of acute respiratory failure if the patient remains intubated following surgery, but, perhaps, CDI should not be querying until they remain intubated for 48 hours (based on Coding Clinic) or remains intubated longer than typical for the surgical pathway without being scheduled for additional surgery as patients are often left intubated when having multi-staged procedures.

Post-op respiratory insufficiency is coded 518.52 but be very wary of applying this code since it applies to both trauma and surgery and is a potential Recovery Auditor target due to its being an MCC.

The alphabetic index directs to 997.39 for postoperative respiratory complication, not elsewhere classified (NEC). Also documentation must clearly establish a cause-and-effect relationship between the condition and the surgery as well as refer to it as a complication. Remember, that the Official Guidelines for Coding and Reporting (Section I.B.18) directs code assignment based on “documentation of the relationship between the condition and the care or procedure.”

The guideline extends to any complications of care, regardless of the chapter the code is located in. Not all conditions that occur during or following medical care or surgery are classified as “complications,” however. There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication.

CDI professionals should query the provider for clarification, if the complication is not clearly documented.

Respiratory failure, on the other hand, can be acute, but if it was directly caused by the surgery, then likely will be a potentially preventable condition (PPC) problem according to the Maryland specific HSCRC guidelines (www.hscrc.state.md.us). Documentation by the physician can be made clear, in many cases, if it states that there likely was a cause other than surgery, but surgery is obviously a contributing factor. Also, acute respiratory failure is easier to code after surgery if the patient already had chronic respiratory failure and an exacerbation documented as caused by many factors including acute pulmonary edema that may or may not be caused by the surgery.

I like the idea of working toward an agreed upon criteria between physicians and CDI/coders/quality staff member. Education on this topic for all is necessary.

As news reports continue to illustrate the extensive damage caused by hurricane Sandy our thoughts and prayers go out to those who live and work in the affected communities.

The Association of Clinical Documentation Improvement Specialists (ACDIS) currently has chapters in some of the hardest hit areas and members throughout the affected regions. We join the entire nation in expressing its sincere concern for the victims of the hurricane and understand that assistance is desperately needed now and will continue to be needed in the weeks of clean-up to come.

Over the coming days, ACDIS will continue to reach out to its local chapter leadership in support and solidarity. If you currently work or live in one of these areas please feel free to share how this storm has affected you by leaving a comment below. Additionally, those who wish to leave their comments of support may also do so.

New Orleans: The NOLA ACDIS Chapter holds its next meeting on April 11, 4-6 p.m., at Semolina’s restaurant in Metairie, LA. For information, email Melissa Mayer melissamayer@ejgh.org.

Indiana: The Central Indiana Chapter is gearing up for its next meeting Wednesday, April 11, 10 a.m. to noon, with featured speaker Nancy Ignatowicz presenting “CDI Success: How Do You Measure It?” For information, contact Susan Bradford at 317/776-7285 or by email at sbradford@riverview.org.

PHIMA: The Pennsylvania AHIMA group holds a CDI-related education session on Friday, April 13, 9 a.m. to 3 p.m., at the Wesley Village Conference Area, in Pittston. The agenda includes:

Nevada: The next Southern Nevada ACDIS meeting will be on Wednesday, April 18, at 5:30 p.m. Guest speaker Karen Zaninovich Parker, RHIT, 3M Health Information Services consulting, will discuss how CDI specialists can begin ICD-10 documentation improvement now. She is making a special trip from Utah to join the Nevada ACDIS Chapter group. Attendees are invited to bring a brown-bag dinner. Admission is free. RSVP to Ailsa Kompare by April 16 at 702/343-7232 or email ailsa.kompare@kindredhealthcare.com.

Tennessee:The TN ACDIS and the THIMA host a joint session Friday, April 20, 8:30 a.m. to 3 p.m., focused on ICD-10 and the CDI program development. The agenda includes:

ICD-10 and Beyond: The changing world of classification systems, Kathy Hallock, RHIA

What you should be doing now to prepare for ICD-10: How you can help your physicians improve documentation practices now, James Kennedy, MD, CCS

Working lunch: HCA’s Approach to CDI.

Group work: groups will choose a diagnosis or procedure where documentation must drastically change to support ICD-10 coding. The groups will discuss ways to improve documentation practices relative to those situations. In the second half of the group work session participants will discuss how to propose and justify a CDI program to hospital administrations.

Reports from group work and open forum

Registration is $120. Online registration closes at the end of the business day on Tuesday, April 17th.
Click here to register. For information contact, Wanda M. Johnson executive director, TN Health Information Management Association, Nashville, at 615/242-7275 or email wanda@thima.org.

Michigan: The MACDIS Chapter will hold its quarterly telephone conference call on Thursday, April 19, noon to 1 p.m. The guest speaker is ACDIS Advisory Board member Fran Jurcak, RN, MSN, CCDS, director of CDI Practice for Huron Healthcare in Chicago. She will discuss ICD-10, goals/objectives of a CDI program, CDI staff productivity standards, leading queries,and the benefits of the CCDS certification.

The July MACDIS conference call is in its planning stages. The October quarterly meeting will be a joint regional meeting in collaboration with the Michigan, Wisconsin, Minnesota, and Northern Illinois, ACDIS associations.

New York: The next Albany, NY-regional ACDIS meeting will be held Wednesday, April 25, 2-4 p.m., at the Krause Center at Samaritan Hospital in Troy. For information, contact Lois Rubin at 518/525-1081 or email LRubin@sphcs.org.

Illinois: The next Northern Illinois ACDIS meeting will be held on Friday, April 27, 12:45 p.m., at Centegra Hospital, in McHenry. For information, contact Colleen Stukenberg at 815/599-6820, or email CStukenberg@fhn.org.

Maryland: The MDHIMA hosts its meeting 1-5 p.m., Thursday, May 3, at the Convention Center in Baltimore. The agenda features ACDIS Advisory Board member Robert S. Gold, MD, and discussion of CDI-related efforts including:

West Virginia: The newly formed West Virginia ACDIS Chapter holds its first meeting Monday, May 14, at 1 p.m., at CAMC Hospital in Charleston. For information, contact Sheila Harrison at 304/389-0689 or email Sheila.Harrison@camc.org.

Kentucky/Illinois: The next session of the Kentucky/Illinois ACDIS Chapter will be Thursday, May 24, 1-4 p.m., at St. Mary’s and Elizabeth Hospital in Louisville, KY. For information, contact Rita Fields at or email rita.fields@BHSI.COM.